HIV Disclosure Practices to Family Among Mexican and Puerto Rican Sexual Minority Men with HIV in the Continental USA: Intersections of Sexual Orientation and HIV Stigma.

Disclosing a seropositive HIV status still is a complex process of assessing the risks, benefits, and potential personal and interpersonal outcomes associated with disclosure, such as stigma, rejection, or emotional support. We examined HIV disclosure practices to family and intersectional stigma related to HIV and sexual orientation among Latino sexual minority men (LSMM) of Mexican and Puerto Rican origin with HIV in the continental USA. Guided by Framework Analysis, we present data from 54 interviews with 33 LSMM participants in HIV care engagement interventions, and 21 project staff implementing the interventions. LSMM disclosed their HIV status to family seeking support. They applied stigma management techniques to manage the information communicated to family about their HIV status, including selective disclosure to some family members, conveying strategic information about the significance of having HIV, non-disclosure, or partial disclosure, silence and deceptions. LSMM HIV disclosure practices to family encompassed appraisals of intersectional stigma related to their sexual orientation and HIV, assessing the potential outcomes of disclosure, and the preservation of family ties.

US public charge policy and Latinx immigrants' thoughts about health and healthcare utilization.

OBJECTIVES: We examined Latinx immigrants' perceptions of US policy related to restrictions on immigrants' use of public resources and their thoughts about the influence of these on immigrants' healthcare utilization. DESIGN: A series of 16 focus group discussions with Latinx immigrant men and women (documented and undocumented) (N = 130) were conducted between May and July 2017 across four US cities. RESULTS: Four central themes emerged: participants attributed the limited resources available for affordable healthcare for many uninsured US immigrants (both documented and undocumented) to the US government's view of immigrants as burdens on public resources and its subsequent unwillingness to dedicate funds for their care; participants expressed concerns, some unfounded, about negative immigration ramifications arising from diagnosis with health conditions perceived to be serious and/or expensive to treat; participants noted that some immigrants avoided using health programs and services to which they were entitled because of immigration concerns; finally, participants described how access to information on immigration laws and healthcare resources, and conversely, misinformation about these, influenced healthcare utilization. CONCLUSIONS: Participants were acutely aware of the image of immigrants as public charges or potential burdens on government resources that underlies US immigration policy. In some cases, participants came to inaccurate and potentially harmful conclusions about the substance of laws and regulations based on their beliefs about the government's rejection of immigrants who may burden public resources. This underscores the importance of ensuring that immigrants have access to information on immigration-related laws and regulations and on healthcare resources available to them. Participants noted that access to information also fostered resilience to widespread misinformation. Importantly, however, participants' beliefs had some basis in US immigration policy discourse. Law and policy makers should reconsider legislation and political commentary that frame self-reliance, the guiding principle of US immigration policy, in terms of immigrants' use of publicly funded healthcare resources.

Does HIV Stigma Predict Social Networks Over Time: A Latent Growth Curve Analysis.

Persons living with HIV (PLWH) with socio-economic vulnerabilities are especially vulnerable to HIV stigma and adverse HIV outcomes. Stigma related to HIV may intersect with marginalized socio-economic conditions to negatively affect social networks. HIV stigma may limit the ability of individuals to sustain social relationships. This study examined the potential cross-sectional and longitudinal associations between HIV stigma and the quality and quantity of social networks for PLWH. PLWH (n = 1,082) who were experiencing housing, employment, and medical care-related difficulties were recruited to participate in a one-year navigation and system coordination intervention to improve housing stability and employment. Neither stigma reduction nor social networks were the main components of the intervention. A series of latent growth curves were estimated to assess the cross-sectional and longitudinal relationships among internalized and anticipated HIV stigma and social networks. Anticipated HIV stigma predicted social networks both cross-sectionally and longitudinally. Internalized HIV stigma predicted social networks cross-sectionally but not longitudinally in this population. These data support the HIV Stigma Framework and suggest that anticipated stigma seems to have a strong association with social networks. As anticipated stigma decreases over time, social network scores increase. Interventions to decrease anticipated HIV stigma as a mechanism of improving social networks warrants further investigation.

Beyond HIV prevention: Additional individual and community-level benefits of PrEP among Latino gay and bisexual men.

BACKGROUND: HIV infections disproportionately impact Latino gay and bisexual men (GBM) in the United States. Pre-Exposure Prophylaxis (PrEP) is a proven prevention strategy that can help reduce new HIV infections in this population. Unfortunately, PrEP adoption and persistence among Latino GBM remain low. The added benefits of using PrEP experienced by Latino GBM can provide important insights to inform the development of PrEP messaging to motivate this population to explore and consider PrEP as an appropriate and acceptable HIV prevention tool. METHODS: We conducted in-depth interviews with Latino GBM PrEP users to explore positive feelings and emotions, and additional benefits gained from using PrEP. Data were analyzed using thematic analysis. RESULTS: A total of 29 Latino GBM completed the study interview. The average age of participants was 30 years, and the mean length of time using PrEP was 17.1 months. Five themes were constructed from the data representing the additional benefits gained by Latino GBM PrEP users, and included: (1) reduced fear, anxiety, and stress about HIV, HIV testing, and sex; (2) feeling empowered and in control of their HIV risk; (3) greater awareness of sexual risk behaviors and sexual health; (4) greater sexual exploration and pleasure, and comfort having condomless sex; and (5) a greater connection to community and a feeling of contributing to the elimination of HIV. CONCLUSIONS: The added benefits identified in this study represent a range of social, emotional, and psychological benefits that Latino GBM experience while using PrEP. They speak to the complementary benefits that PrEP can bring to Latino GBM who decide to use the medication, that go beyond HIV prevention. These findings can inform the development of future PrEP messaging to help improve motivation for PrEP uptake and persistent use among Latino GBM.

Acceptability and Appropriateness of Digital PrEP Interventions for Black and Latina Cisgender Women: Perspectives From Service Providers in Los Angeles County.

BACKGROUND: Black and Latina cisgender women (BLCW) experience disproportionately high rates of HIV infection compared with White women. BLCW also experience disparities in uptake of pre-exposure prophylaxis (PrEP), a highly effective HIV prevention strategy. Digital technology interventions may help to improve PrEP accessibility among BLCW and address barriers to receiving PrEP services in clinical settings. METHODS: We conducted a formative implementation research project with service providers to explore the use of digital technology interventions to improve PrEP care continuum outcomes among priority populations in Los Angeles County. A thematic analysis approach was then used to assess the perceived acceptability and appropriateness of digital PrEP interventions for BLCW. RESULTS: Of the five technology products presented, service providers viewed the stand-alone telemedicine platforms as the most acceptable intervention type for BLCW. Service providers also noted perceived benefits and barriers that BLCW may experience in using stand-alone telemedicine platforms, and offered recommendations for tailoring the products to meet the individual needs of BLCW. CONCLUSIONS: Digital PrEP interventions may help address barriers BLCW experience in accessing PrEP in clinical settings. We offer suggestions of implementation strategies to optimize the use of digital PrEP interventions among BLCW.

Using social and sexual networking mobile applications to promote HIV testing, medical care and prevention services among Latino men who have sex with men in Los Angeles County, California, USA.

HIV disproportionately affects Latinos versus Whites, with Latinos having higher rates of HIV. Additionally, many HIV-positive Latinos are unaware of their infection. Proyecto Protégete, an HIV prevention intervention developed for Latino men who have sex with men (MSM), used social and sexual networking mobile applications (apps) to recruit individuals for HIV testing and linkage to medical care and prevention services. This study occurred in Los Angeles County, California, USA from December 18, 2015 to April 22, 2017. The study's primary aim was to assess Proyecto Protégete's ability to successfully recruit Latino MSM involved in high-risk sexual activities. A secondary aim was to evaluate its capacity to promote HIV testing and linkage to HIV medical care and prevention services among this population by comparing it to two programs with similar samples. Comparisons using Fisher's Exact Test were conducted between Proyecto Protégete and the HIV testing program of the agency in which Proyecto Protégete was located and the County-funded HIV testing programs to compare the samples' rates of HIV-positive Latino MSM identified through HIV testing and linked to HIV medical care and prevention services. Participants were recruited through seven apps. In Proyecto Protégete, 9,573 individuals completed the screener, 4,657 were eligible, and 359 (7.7% of those eligible) enrolled. Among those enrolled, 79% reported anal sex without a condom in the previous twelve months; 51% reported anal sex under the influence of alcohol. The HIV positivity rates were as follows: Proyecto Protégete, 1.71%; the agency, 1.25% (p = .293, compared to Proyecto Protégete); and the County, 1.09% (p = .172, compared to Proyecto Protégete). The rates of those confirmed as new HIV-positives and linked to medical care within 30 days were as follows: Proyecto Protégete, 71.4%; the agency, 81.5% (p = .450, compared to Proyecto Protégete); and the County, 77.3% (p = .503, compared to Proyecto Protégete). Proyecto Protégete had a higher rate of linked referrals to prevention services than the agency's testing program (19.5% versus 8.3%, p < .001). Proyecto Protégete experienced successes in some areas but not in others. Future research should build on Proyecto Protégete's experiences to promote HIV-related services among Latino MSM.

Barriers and motivators to pre-exposure prophylaxis uptake among Black and Latina transgender women in Los Angeles: perspectives of current PrEP users.

The purpose of this qualitative study was to identify barriers and motivators to PrEP uptake from the perspective of Black and Latina transgender women (TW) who are currently using PrEP to suggest intervention and outreach activities to increase PrEP uptake in this population. The Information-Motivation-Behavioral Skills Model guided the development of the semi-structured interview guide. A thematic analysis approach was used to analyze the data. Perceived barriers to PrEP uptake included structural and logistic barriers, language and cultural barriers to medical engagement, lack of transgender competent or gender-affirming care, and prioritizing hormone therapy over the use of PrEP. To increase PrEP uptake among BLTW, participants recommended disseminating PrEP information through a variety of methods, highlighting relationship and sexual health benefits of using PrEP, and developing effective patient-provider communication. Our findings highlight several ways to promote PrEP among BLTW. PrEP promotion should be integrated into gender-affirming care and supported by peer education and navigation services that reach BLTW in both clinic and community settings.

PrEP discontinuation among Latino/a and Black MSM and transgender women: A need for PrEP support services.

PURPOSE: Disparities persist in HIV infection among Black and Latino men who have sex with men (BLMSM) and Black and Latina transgender women (BLTW). Increasing uptake and subsequent consistent use of pre-exposure prophylaxis (PrEP), an effective biomedical strategy for preventing HIV acquisition, can dramatically reduce HIV incidence in these populations. The purpose of this study was to explore reasons for PrEP discontinuation among BLMSM and BLTW living in Los Angeles County to inform the development of support services for these populations to remain persistent with their PrEP regimen. METHODS: In-depth, semi-structured interviews were conducted with 15 BLMSM and 7 BLTW who reported either temporary or indefinite PrEP discontinuation. A thematic analysis approach was used to analyze qualitative data. RESULTS: Four themes emerged related to reasons for PrEP discontinuation, including: (1) lower perceived HIV risk related to changes in sexual behavior; (2) structural or logistical barriers (e.g., lapse or loss of health insurance, cost, difficulty navigating complex medical systems); (3) anticipated and experienced medication side effects, with a sub-theme of interactions between PrEP and feminizing hormone medications; and (4) challenges with medication adherence. CONCLUSIONS: PrEP is an important prevention tool for BLMSM and BLTW, particularly during periods of heightened HIV risk. However, both individual (e.g., inability to adhere to medication, changes in HIV sexual risk behaviors) and structural/logistical (e.g., loss of insurance, navigating complex medical systems) factors can cause temporary or indefinite PrEP discontinuation. Additional support services, beyond those offered by medical providers, are needed to help BLMSM and BLTW PrEP users overcome barriers to discontinuation and assist them to remain persistent with their PrEP regimen. We describe potential options for support services such as PrEP case management, expanded PrEP navigation services, or text messaging services.

Predictors of Internet Health Information-Seeking Behaviors Among Young Adults Living With HIV Across the United States: Longitudinal Observational Study.

BACKGROUND: Consistent with young adults' penchant for digital communication, young adults living with HIV use digital communication media to seek out health information. Understanding the types of health information sought online and the characteristics of these information-seeking young adults is vital when designing digital health interventions for them. OBJECTIVE: This study aims to describe characteristics of young adults living with HIV who seek health information through the internet. Results will be relevant to digital health interventions and patient education. METHODS: Young adults with HIV (aged 18-34 years) self-reported internet use during an evaluation of digital HIV care interventions across 10 demonstration projects in the United States (N=716). Lasso (least absolute shrinkage and selection operator) models were used to select characteristics that predicted whether participants reported seeking general health and sexual and reproductive health (SRH) information on the internet during the past 6 months. RESULTS: Almost a third (211/716, 29.5%) and a fifth (155/716, 21.6%) of participants reported searching for general health and SRH information, respectively; 26.7% (36/135) of transgender young adults with HIV searched for gender-affirming care topics. Areas under the curve (>0.70) indicated success in building models to predict internet health information seeking. Consistent with prior studies, higher education and income predicted health information seeking. Higher self-reported antiretroviral therapy adherence, substance use, and not reporting transgender gender identity also predicted health information seeking. Reporting a sexual orientation other than gay, lesbian, bisexual, or straight predicted SRH information seeking. CONCLUSIONS: Young adults living with HIV commonly seek both general health and SRH information online, particularly those exploring their sexual identity. Providers should discuss the most commonly sought SRH topics and the use of digital technology and be open to discussing information found online to better assist young adults with HIV in finding accurate information. Characteristics associated with health information-seeking behavior may also be used to develop and tailor digital health interventions for these young adults.

Delivering PrEP to adults with "low" or "no" HIV risk and youth: experiences and perspectives of PrEP providers.

Health care providers have an important role to play in expanding PrEP uptake to populations disproportionately burdened by HIV. In this study, in-depth, semi-structured qualitative interviews were conducted with 20 PrEP providers in Los Angeles, California to explore their experiences and perspectives prescribing PrEP. Overall, the findings indicate that providers generally adhered to US CDC clinical guidelines in determining PrEP eligibility. However, they also identified special considerations with respect to adults with "low" or "no" HIV risk. Three themes were developed from the data related to the delivery of PrEP to such individuals: 1) patients may not disclose sexual behaviours; 2) patient autonomy and agency; and 3) the importance of PrEP in gay male monogamous relationships. Two additional themes were identified related to prescribing PrEP to young people under the age of consent: 4) the need for more PrEP and sexual health education with youth and 5) challenges in providing PrEP to youth without parental consent. Findings highlight the importance of providing PrEP to patients who could potentially benefit from adoption, whether or not they present with clear behavioural indicators for PrEP. Providers should also consider the potential barriers to delivering PrEP to youth to ensure successful adoption among members of this population.

Associations Between Social Support and Social Media Use Among Young Adult Cisgender MSM and Transgender Women Living With HIV.

Social media platforms offer the opportunity to develop online social networks. Use of these platforms has been particularly attractive to younger sexual and gender minority individuals as well as those living with HIV. This cross-sectional study examined the perceived level of social support and associations with social media use among youth and young adult cisgender men who have sex with men (MSM) and transgender (trans) women living with HIV and examined these associations by gender identity. The study drew from baseline data collected from 612 cisgender MSM and 162 trans women enrolling in one of 10 demonstration sites that were part of a Health Resources and Services Administration Special Projects of National Significance initiative. The individual projects were designed to evaluate the potential for social media/mobile technology-based interventions to improve retention in care and HIV health outcomes. The data used in this study came from baseline surveys completed when participants enrolled in a site between October 2016 and May 2018. Results demonstrated that a significantly greater proportion of MSM than trans women participants reported the use of social media platforms (e.g., Facebook: MSM = 86%, trans women = 62%; Instagram: MSM = 65%, trans women = 35%). Furthermore, increased social media use improved perceptions of social support only among MSM participants (direct adjusted OR = 1.49) and not trans women participants (gender identity interaction term adjusted OR = 0.64). These results revealed that MSM participants perceived greater social benefit from the use of social media platforms than trans women, which could be a result of generalized online transphobia experienced by trans women. More nuanced data on various social media platforms, that is, anonymous versus profile-based, and group differences, are needed to better understand how social media platforms can be best utilized to optimize health care outcomes among sexual and gender minority youth and young adults living with HIV.

Qualitative Evaluation of Social Media and Mobile Technology Interventions Designed to Improve HIV Health Outcomes for Youth and Young Adults Living With HIV: A HRSA SPNS Initiative.

Youth and young adults living with HIV (YYALH) are less likely to be engaged in HIV care, adhere to their medications, and achieve viral suppression compared to older adult populations. In the United States, the majority of YYALH belong to racial/ethnic, sexual, and gender minority groups. HIV care interventions are needed that specifically target YYALH and that exploit the use of social media and mobile technology (SMMT) platforms, where youth and young adults have a ubiquitous presence. We conducted a qualitative evaluation of SMMT interventions included in a Health Resources and Services Administration Special Projects of National Significance initiative designed to improve medical care engagement, retention, and medication adherence to achieve viral suppression among YYALH. However, in this study, only young adults living with HIV (YALH) ages 18 to 34 years participated. A total of 48 YALH were interviewed. The data were analyzed using thematic analysis and revealed three main themes supporting the usefulness of the SMMT interventions, which included (1) acceptability of SMMT interventions in managing HIV care with subthemes of medical information accessibility, reminders, and self-efficacy; (2) feelings of support and personal connection afforded by SMMT interventions; and (3) SMMT interventions help to alleviate negative feelings about status and mitigate HIV-related stigma. A few participants identified problems with using their respective intervention, primarily related to the functionality of the technologies. Overall, findings from our qualitative evaluation suggest that SMMT-based interventions have the potential to increase engagement and retention in care, support YALH in adhering to medication, and help them adjust to their diagnosis.

"Holidays Come, Sundays Come. It is Very Sad to be Alone": Transnational Practices and the Importance of Family for Mexican and Puerto Rican Latinxs Living with HIV in the Continental U.S.

Latinxs continue to be overrepresented in the U.S. HIV epidemic. We examined the transnational practices, family relationships, and realities of life of Mexicans and Puerto Ricans living with HIV in the continental U.S. We conducted qualitative interviews with 44 persons of Mexican and Puerto Rican origin participating in HIV care engagement interventions. Framework Analysis guided our data analysis. Among participants, a strong connection to the family was intertwined with transnational practices: communication, travel to their place of origin to maintain family ties, and material and/or emotional support. Separation from their family contributed to social isolation. Many participants lacked emotional support regarding living with HIV. Transnational practices and family relationships were intrinsic to the experiences of Mexicans and Puerto Ricans living with HIV in the continental U.S.; and may help understand the points of reference, health-seeking behaviors, and support sources that influence their health, well-being and engagement in HIV care.

Experiences of Pre-Exposure Prophylaxis (PrEP)-Related Stigma among Black MSM PrEP Users in Los Angeles.

Black men who have sex with men (BMSM) are disproportionately affected by HIV infection in the USA. Pre-exposure prophylaxis (PrEP) is a proven efficacious biomedical prevention strategy with the potential to alter significantly the course of the epidemic in this population. However, the social stigma attached to PrEP and those who use it may act as a barrier to the uptake and continuation of PrEP among high-risk BMSM. In-depth, semi-structured qualitative interviews were conducted with 26 BMSM PrEP users to explore their experiences of stigma related to their PrEP use. BMSM reported multiple experiences or manifestations of PrEP-related stigma, which included (1) perception that PrEP users engage in elevated sexual risk behaviors; (2) conflicts in relationships attributed to PrEP; (3) experiences of discomfort or judgment from medical providers; (4) assumption that PrEP users are HIV-positive; and (5) gay stigma in families limiting PrEP disclosure. The experiences of stigma typically occur within the context of PrEP disclosure and have significant personal and social consequences for PrEP users. Efforts to address PrEP and other social-stigmas within the Black community may help facilitate PrEP uptake and continuation with BMSM.

Predictors of Awareness, Accessibility and Acceptability of Pre-exposure Prophylaxis (PrEP) Among English- and Spanish-Speaking Latino Men Who have Sex with Men in Los Angeles, California.

Uptake of pre-exposure prophylaxis (PrEP) among Latino men who have sex with men (LMSM) remains low. We examined awareness, accessibility, acceptability and use of PrEP among LMSM. LMSM were recruited using social/sexual networking apps. Multiple Logistic regressions identified significant predictors of PrEP awareness, accessibility and acceptability. Among 276 participants, only 6% reported current PrEP use. Among non-PrEP users, 85% reported PrEP awareness, 71% indicated high likelihood of future PrEP use, but only 35% reported knowledge about accessing PrEP. In multiple logistic regressions, a lower likelihood of PrEP awareness was associated with lower level education, whereas a higher likelihood was associated with reporting 6-10 or over 10 sexual partners. A lower likelihood of PrEP accessibility was associated with lower level education and undocumented status. A lower likelihood of PrEP acceptability was associated with an income of $15,001-30,000, whereas a higher likelihood was associated with lower level education and reporting 6-10 or over 10 sexual partners. PrEP promotion targeting Latino MSM should be expanded for those with lower levels of education and those who are undocumented.

Authorship Correction: Promising Approaches for Engaging Youth and Young Adults Living with HIV in HIV Primary Care Using Social Media and Mobile Technology Interventions: Protocol for the SPNS Social Media Initiative.

[This corrects the article DOI: 10.2196/10681.].

Experiences of Pre-Exposure Prophylaxis Stigma, Social Support, and Information Dissemination Among Black and Latina Transgender Women Who Are Using Pre-Exposure Prophylaxis.

Purpose: In the United States, HIV disproportionally affects Black and Latina transgender women (BLTW). Pre-exposure prophylaxis (PrEP) is a proven biomedical method for preventing HIV acquisition. However, the social stigma attached to using PrEP may deter uptake and persistence of PrEP among BLTW, two highly vulnerable populations. The purpose of this study was to explore the experiences of PrEP stigma among BLTW who are using PrEP in Los Angeles County. Methods: In-depth, semistructured interviews were conducted with BLTW PrEP users (N=19) to explore experiences of anticipated, enacted, and internalized PrEP stigma within the context of their unique social and contextual factors. A thematic analysis approach was used in the analysis of qualitative data. Results: We noted an underlying theme of HIV stigma related to participants' identification as trans women that served as the social context for other experiences. In addition, our data revealed five themes related to the experience of using PrEP. Three themes were specifically related to PrEP stigma and included: (1) Perception that BLTW PrEP users are HIV-positive; (2) perception that BLTW PrEP users engage in elevated sexual risk behaviors; and (3) negative labels ascribed to BLTW PrEP users. A fourth theme identified was the positive experiences of social support after PrEP disclosure reported by BLTW. Our fifth theme identified involved the dissemination of PrEP information by BLTW to friends/peers and sex partners. Conclusion: BLTW experience PrEP stigma within the context of PrEP disclosure. This experience is underscored by existing experiences of HIV stigma connected to their identity as trans women. PrEP providers should prepare BLTW to use selective disclosure practices when revealing their PrEP use to help minimize experiences of PrEP stigma or potential physical harm. PrEP implementation programs should also support peer-to-peer PrEP education programs for transgender women to promote positive views of PrEP and help facilitate PrEP uptake in this population.